# NTSB CEN17LA307: Pegasus Quantum, N56092, Fort Atkinson, WI, August 9, 2017 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: August 8, 2017, 20:05 local (Aug 9, 2017, 01:05 UTC) - Place: Fort Atkinson, WI - Coordinates: 42.967777, -88.809722 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.9678&lon=-88.8097&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report October 10, 2018 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Flight Standards District Office - NTSB case key (mKey): 95777 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17LA307 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95777/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95777 - Page: https://openairdocs.org/ntsb/CEN17LA307 ## Probable cause The student pilot's failure to maintain aircraft control during a go-around, which resulted in impact with water. Contributing to the accident was the non-instructor sport pilot's decision to allow the student pilot to fly the aircraft. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Pegasus QUANTUM, 1 case](https://openairdocs.org/ntsb-findings/01062023/cases.md?model=05901G8), [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Pegasus QUANTUM, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05901G8), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Pegasus QUANTUM, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=05901G8), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Pegasus QUANTUM, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05901G8), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Pegasus QUANTUM, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05901G8), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The sport pilot (who was not an instructor) and the student-pilot-rated passenger were making a local personal flight in the weight-shift-control (WSC) aircraft. The pilot was seated in the front seat, and the passenger was seated in the rear seat. A flight instructor observed the WSC aircraft make several stable visual approaches to a grass runway. The last approach was unstable, which the flight instructor attributed to the passenger attempting to fly the approach. A go-around was initiated, which transitioned to a diving left turn that continued to impact with a river. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The aircraft's two "training bars," which were designed for use by a flight instructor flying from the rear seat, were each deformed to the left, consistent with the passenger gripping them as the aircraft impacted the river. The passenger had recently accomplished a solo flight in a fixed-wing airplane, which has reverse control inputs from a WSC aircraft. The passenger likely made incorrect control inputs during the go-around, due to negative transfer of learning from his fixed-wing airplane training. Because of the position of the training bars, the front-seat pilot would have been unable to see the inputs being made by the person in the rear seat. Although toxicological testing indicated that the pilot had used diphenhydramine at some point before the accident, the blood levels of this drug can change postmortem, and the pilot's blood levels at the time of the accident may have been significantly lower than the therapeutic range. Based on the accident scenario and available information, the pilot's use of diphenhydramine most likely did not contribute to the accident. ## Factual narrative The single-engine, propeller-driven, pusher-configured, two-seat tandem WSC aircraft was manufactured by P&M Aviation in 2007 and purchased by the pilot in 2009. Powered by a Rotax 912 four-stroke engine and equipped with a three-bladed composite propeller, the aircraft had a pilot-passenger "pod" suspended by a triangular frame, hinged below the wing, which permitted weight shift control of pitch and roll. The pilot and passenger each had a headset to allow for in-flight communications. Aircraft control inputs for pitch and roll were made via a control bar and were the reverse of a fixed wing airplane. For example, pushing right on the control bar of a WSC aircraft resulted in a turn to the left, and pushing forward on the control bar resulted in an increased pitch attitude. Extension "training" bars were installed to allow for control inputs from the rear seat. These bars, which were designed for use by a flight instructor flying from the rear seat, were behind the front seat pilot's field of view. On August 8, 2017, about 2005 central daylight time, a Pegasus Quantum Q-2 weight-shift-control (WSC) aircraft, N56092, impacted a river during a go-around at the Fort Atkinson Municipal Airport (61C), Fort Atkinson, Wisconsin. The sport pilot and the pilot-rated passenger were fatally injured, and the aircraft was substantially damaged. The aircraft was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions prevailed for the local flight, which departed 61C about 1930. According to a flight instructor located on the ramp at 61C, the pilot made a solo landing in the aircraft about 1915. After the passenger was loaded in the rear seat, the aircraft departed from runway 21 and subsequently made several stable low approaches to a parallel grass runway. The aircraft then made an "unstable approach," which the flight instructor attributed to the passenger possibly flying the approach. He heard the engine power increase and saw the aircraft bank to the left. The left bank steepened, and the aircraft descended rapidly until it impacted a river and submerged. The Milwaukee County Medical Examiner, Milwaukee, Wisconsin, performed an autopsy on the pilot and determined that the cause of death was blunt force injuries. No significant natural disease was identified. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing and identified diphenhydramine in urine (unquantified) and at 0.049 µg/ml in cavity blood. Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. It is available over the counter under the names Benadryl and Unisom. Diphenhydramine carries the following warning: "may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." Compared to other antihistamines,diphenhydramine causes marked sedation; it is also classed as a central nervous system depressant. Altered mood and impaired cognitive and psychomotor performance may also be observed. The therapeutic range or the range of blood levels where psychoactive effects would be routinely expected is between 0.0250 and 0.1120 µg/ml. It is possible for diphenhydramine levels to either increase or decrease postmortem. The Milwaukee County Medical Examiner performed an autopsy on the passenger and determined that the cause of death was multiple blunt force injuries. No significant natural disease was identified. The FAA's Bioaeronautical Sciences Research Laboratory performed toxicology testing and did not identify any tested-for substances. The 51-year-old pilot held a Federal Aviation Administration (FAA) sport pilot certificate for WSC aircraft and a repairman certificate for light sport aircraft in the WSC category. The pilot had never applied for a medical certificate nor was he required to do so. The 16-year-old passenger held a student pilot certificate and had recently accomplished a solo flight in a fixed-wing airplane. The accident flight was the student pilot's first flight in a WSC aircraft. A postaccident examination revealed that both wing tip straps were intact. All of the battens and luff lines were in place and attached. All flying wires were intact, except for a rear starboard wire, which had fractured and was wrapped around the propeller hub. The fracture surface of the rear starboard wire had a broomstraw appearance. The trailing edge of the wing contained one damaged area where the propeller was protruding from the wing. A manufacturer-recommended Bettsometer testing device was used to measure the strength of the aircraft's fabric surfaces. All areas tested above the recommended 1,360 grams of force in both chord-wise and span-wise directions, except for a section of the starboard wing, which tested at 1,100 grams of force. The starboard wing's fabric was not torn. The engine was hand rotated and mechanical continuity was confirmed. The spark plugs exhibited a normal condition. The oil tank was at the full level, and the fuel tank contained about 11 gallons of fuel. The aircraft's two "training" bars were each bent to the left. The most significant bending occurred near the bottom of the bars, where they connected to the base tube. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. ## Aircraft - Registration: [N56092](https://openairdocs.org/deregistered/N56092-2019-05-06), registration cancelled 2019-05-06, S/N 173671, built 2007 (OpenAirDocs) - Reported make and model: PEGASUS QUANTUM (Q-2) - Registry model: [Pegasus QUANTUM](https://openairdocs.org/model/pegasus-quantum) (registry code 059032C) (OpenAirDocs) - Registry engine: [Rotax 912 series](https://openairdocs.org/engine/rotax-912-series) (registry code 55569, 4 cycle) (OpenAirDocs) - Category: Weight-shift - Serial number: 173671 - Year built: 2007 - Engines: ROTAX 912 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental light sport (Special) - Departed: 61C, Fort Atkinson, WI - Destination: 61C, Fort Atkinson, WI - Airport: 61C, Fort Atkinson Muni - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: fatal; sport pilot; airplane ratings: single-engine land; last flight review April 23, 2017; seat: front; restraint: 4-point; toxicology performed; flight hours: 400 total, 400 in this make and model - Student pilot; age 16; injuries: fatal; student; medical: class 1, without waivers/limitations; seat: rear; restraint: 4-point; toxicology performed; flight hours: 20 total, 0 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 59 °F - Altimeter: 30.12 inHg - Observed at: KRYV, 13 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20170808012819A](https://openairdocs.org/incident/20170808012819A), Aug 8, 2017: Pegasus QUANTUM, Fort Atkinson, WI, Destroyed, 2 fatal. Tuesday August 8, 2017 at 2005 local time, an experimental light sport weight shift aircraft registration number N56092 impacted into the rock river 300 yards… ## Docket (6 files) The files NTSB released with the investigation on September 6, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95777. 3.2 MB in all. - Overhead View of Flightpath - Witness Perspective (item 1, .PDF, 1 photo, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466362&FileExtension=.PDF&FileName=Overhead%20View%20of%20Flightpath%20-%20Witness%20Perspective-Master.PDF - FAA Inspector Statement (item 2, .PDF, 421 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466363&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Exam Notes and Witness Perspectives (item 3, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466364&FileExtension=.PDF&FileName=Exam%20Notes%20and%20Witness%20Perspectives-Master.PDF - Photos of Mechanic's Exam (item 4, .PDF, 5 photos, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466365&FileExtension=.PDF&FileName=Photos%20of%20Mechanic%27s%20Exam-Master.PDF - Toxicological Report - Pilot (item 5, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466366&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Pilot-Master.PDF - Toxicological Report - Passenger (item 6, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466367&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Passenger-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.